Read an Excerpt
Looking at the Risks
Fred and I understood the importance of reviewing the facts before making a decision to start a family. Was parenthood worth the risks involved in managing my own moods without medication, let alone potential risks to our baby? The questions in our minds were spiraling endlessly. We needed answers.
In October 1990, Fred and I had an appointment for genetic counseling at Spectrum Health Genetics in Grand Rapids, Michigan. Judy Hiemenga, M.D., my obstetrician-gynecologist, referred us. Our primary concern was what might happen to our baby if I continued to take lithium while pregnant. We also wanted to learn about the potential risks of continuing any of the prescriptions or over-the-counter drugs I was taking. My mother joined us at this meeting to provide moral support and to help in the review of our family history.
Scheduling an appointment with a genetic counselor before conception is a wise first step in planning any pregnancy, especially if you're affected with bipolar disorder. Asking your ob-gyn to refer you to a genetic counselor works well because the doctor is familiar with your history and can easily send your records. I encourage you to bring a family member who is familiar with your health historyand if that's not possible, then bring as much pertinent information with you as you can.
Because I was taking lithium (lithium carbonateEskalith is the brand name) to treat my bipolar disorder, we focused on its potential risks to our developing baby. If you are on another medication, your concerns will be different. Be prepared to discuss all your medications in detail with your genetic counselor. If the genetic clinic in your area does not offer preconception planning, it can refer you to one that does.
Appendix A, written by Helga Valdmanis Toriello, Ph.D., contains important information about genetic counseling. Although the information is quite technical, Dr. Toriello does a thorough job of explaining the importance of this step. She has included a table that summarizes the medications used to treat bipolar disorder and the risks to the unborn baby of anomalies (i.e., abnormalities).
Letters summarizing our genetic counseling session were sent by Dr. Toriello to Dr. Hiemenga and me. An important objective for our genetic counselor was to research lithium risks to our baby and she did her job well. She described, in detail, several abnormalities (with accompanying statistics) that could occur while taking lithium during pregnancy. Since bipolar disorder is treatable, a lesser concern to us was finding out that our children could also have the condition.
After our genetic counseling session, and especially after reading the summary letter, I felt as if the wind had been knocked out of me. Fred and I wanted to have a babywe desperately wanted to start a family. Our odds of having a safe pregnancy and a healthy baby seemed remote. After considering all the facts, Fred and I decided that if we moved forward with our goal to have a baby, I would discontinue lithium. My next step was to learn more about that decision.
I wanted to know how long it would take before my body was lithium free. I talked with a pharmacist I knew and respected. His conclusion, based on research he obtained from Micromedex Inc. (a drug evaluation monograph), is that once lithium was discontinued, I would have a good margin of safety at twelve days.
I also discussed going off lithium in detail with my psychiatrist, Ingrid Eerdmans. (Her instructions are summarized in Chapter 4.) It is imperative that you consult with your doctor about all medication changes.
The NAMI Advocate (Spring/Summer 2004) reported that a 2004 study by Yonkers et al. found that:
Because bipolar disorder emerges during young adulthood and persists throughout the lifespan, women of childbearing age are at risk for this illness. Pregnancy and delivery can influence the symptoms of bipolar disorder: pregnant women or new mothers with bipolar disorder have a sevenfold higher risk of hospital admission and a twofold higher risk for a recurrent episode, compared with those who have not recently delivered a child or are not pregnant.
Careful planning for pregnancy can help women with bipolar disorder to optimally manage their illness to minimize their symptoms and avoid risks to the fetus. Experts suggest it is important to avoid sudden changes in medication during pregnancy, because such changes may increase side effects and risks to the fetus and also increase the risk of relapse of the illness before or after the woman gives birth.
I've always been one to bite off more than I can chew, and this wasn't any different. Fred and I were determined to go against the odds, conquer our fears, and bask in the joys of having a family of our own. It became not only a distant dream but a reachable destiny.
The next section was written by Jay Carter, a licensed psychologist who is certified in psychoactive substance abuse disorders by the American Psychological Association. He focuses on two important points that will help in planning your pregnancy.
Doctor's Note by Jay Carter, PsyD, DABPS
Bipolar is a spectrum disorder. That means it varies in intensity depending on what genes are awry and how many genes are awry. It also varies (within spectrum limits) depending on the amount of stress that comes from the environment.
If a woman has been hospitalized in the past for bipolar disorder, I would recommend that she obtain a legal document for mental health power of attorney, which appoints someone to be her legal guardian for a specified period of timefor example, from the time she goes off medication to six weeks after she gives birth. It must be irrevocable for that period. The assignee would be her spouse, her psychiatrist, a parent, or a trusted friend. This person should be able to legally admit the assignor to a mental health unit against her (current) will, for the purpose of protecting her and her unborn child from harm and to enable a smooth transition during pregnancy.
Someone who is manic or depressed loses part of his or her executive function. The executive function is in the prefrontal lobe of the brain; it enables us to see the big picture and the context of situations. The executive function can be totally lost or lost just to the degree that one is dysfunctional in significant ways. It includes the part of the imagination that enables us to understand the consequences of our actions. It lets us put ourselves in someone else's place and have empathy.
When the mind races six times faster than normal (as it often does with bipolars), the cognitive (concrete) part of the brain takes over all the brain's energy, leaving little for the executive function in the prefrontal lobe. This can be seen in brain scans of people who are manic. We lose our common sense, so to speak, but usually not to the degree that it causes catastrophic, irreversible acts to ruin our lives. One can say, 'He would never do that in his right mind' about someone who is manic.
Making the Decision
I will always remember the day that Fred and I decided we were going to try to have a baby. It was December 7, 1990; it was a day that continues to shape our lives. I was a medical center representative for a pharmaceutical company at the time. I was traveling for business, staying in a quaint hotel overlooking Lake Michigan. I extended my stay, Fred joined me, and we took this opportunity to focus on our future. The apprehension and uncertainty that we had been feeling was replaced with a surge of peace and joy.
Fred comments as follows:
When Kristin and I started talking about having a baby, I was ecstatic about being a dad. I had always thought I would like to have children, but at the same time I was concerned for Kristin's health. We had no way of knowing how being off lithium would affect her. This was the only Kristin I knew. I felt a mixture of emotions: excitement at the idea of parenthood, but also apprehension about her well-being.
Although we were unsure of our immediate future, Fred and I were driven to begin this new chapter in our lives. Together we started breaking down this life-changing decision into manageable parts. We knew it would be safest for the baby if I didn't take lithium prior to conception and throughout the pregnancy. At the time, we believed that taking any kind of medication during that period could put our baby at risk.
I was terrified at the thought of going off lithium. Fred, too, was concerned with the risks involved for me. Would this sacrifice be too high a price to pay to have a child? I had been on lithium continuously for close to twelve years. Before I started taking it, my life had been a roller coaster. I felt as if I were trapped in a body with no control. At times I thought I was in control, but looking back, I can see that those were the times that I was manic.
My manic episodes included the following uncontrollable behavioral characteristics: a racing mind, the pressure to say everything I was thinking, an exceedingly happy mood, grandiose thoughts, and the frivolous spending of money. While hypomanic (i.e., having mild mania), I experienced some of the same symptoms, but they were not as intense.
The Bipolar Disorder Survival Guide (Miklowitz, 2002) points out that 'a true hypomanic episode involves an observable change in functioning from a prior mood state. A hypomanic person sleeps less, feels mildly or moderately elated or irritable, and has racing thoughts or becomes talkative'
Because I refer to the term hypomanic throughout the book, I'm giving an example of how it affects me. There are times even today when I know that I'm hypomanic. It's often triggered by a self-imposed goal. My hypomanic symptoms include intense stress, agitation, and anxiety. The compulsion I feel to complete my task is all consuming. Although I give myself deadlines to stop working, I rarely stop on my own. The pressure is there to continue. Time passes quickly, and I keep on working. Once I stop, my thoughts are still racing. My mind and body feel like a revved-up car engine with no hope of running out of gas.
During my depressed periods I felt lonely, isolated, and hopeless. I didn't want to open the door to mania or depression as a result of our decision for me to discontinue lithium. However, I did realize it would be temporary.
Our primary goal was to increase our chance of having a healthy baby. We knew that this would involve making some lifestyle changes. Our initial challenge was to identify the areas in my life that were stressful. The first thing that came to mind was my career.
Fred and I knew that I would have to quit my job. My career was extremely technical and stressful. I knew I wouldn't be able to effectively fulfill the responsibilities of a pharmaceutical representative once I discontinued lithium. Also, I had an extensive territory that required overnight travel and long hours on the road. I didn't know if I would be able to drive safely or communicate effectively with others. Thus I could not perform my job competently once I went off lithium. The stress level would surely send me into a manic episode.
So Fred and I developed a plan.
The Importance of Journaling
It was crucial that I record each stage of my pregnancy. Writing in my 'pregnancy journal' was one of the most effective ways to monitor myself from preconception through postpartum. I started writing in my pregnancy journal when Fred and I made the decision to have a baby. I knew it was important to record how we felt about this decision before I discontinued lithium. Writing in my pregnancy journal served many purposes.
Once I quit taking lithium, my journal helped me to maintain control; this is the antithesis of being off lithium. I didn't think I'd have much control over my racing mind and moods once I stopped taking the drug. My thoughts and feelings made more sense when I recorded them. It was a way to compartmentalize the utter chaos buzzing around in my mind.
Once I wrote them down, I had a sense of temporary peace. This was my way of 'reeling myself in' when necessary. Writing my feelings down also helped me to manage and cope with stress and agitation. My journal was always there, and it immediately became part of my support system. It was my 'safe place'my sounding board.
Recording specific dates helped me to put my life in perspective. If I had not documented dates, everyday events and milestones would have become one gigantic blur. It was another way in which I sought to exert control when I felt it slipping away. For many bipolars, dates are a touchstone in our mind-set.
I recorded and monitored the schedule that Dr. Ingrid Eerdmans, my psychiatrist, recommended for discontinuing lithium. The act of writing helped me to control hypomanic behaviors. When I was depressed and worried excessively, writing helped me to express and understand those feelings. Keeping track of my thoughts and progress helped me to see myself throughout this challenging time. My pregnancy journal kept me on track and validated me.
Journaling was not new for me. I had kept a daily diary from ages ten to twenty. Even during college, I occasionally wrote in a journal to help sort out my emotions. Writing has always been a safe haven for my feelings and thoughts that others might not have understood.
I realize, however, that not everyone wants or is able to keep a written journal. That's okay; there are several ways to journal. Using a computer or an audiotape to help manage your bipolar symptoms can also help you to organize your thoughts and record your progress. Ongoing communication with your support team (i.e., partner, medical professionals, friends, and family) is another effective tool.
In this book, I focus on keeping a written journal because it worked so well for meespecially in managing my first pregnancy. During my second pregnancy, I used my calendar to supplement my journal. Use a method of journaling that works for you.
For my first pregnancy, I started writing down my feelings in December, as soon as we had made the decision. It was as if I were trying to validate myself. At that point I didn't realize that my journal would serve as a lifeline prior to conception, during pregnancy, and after the birth of our baby. As you can imagine, bipolar journals can be very wordy. All those details I felt compelled to write about went on and on. Throughout this book you will find italicized excerpts from my journal. Many journal entries have been omittedfor your benefit (unless you're like my dad and enjoy an occasional nap while reading).
December 16: Fred and I are thrilled about trying to have a baby. There's no question in my mind that this is the right thing to do. Also, the timing is right!
On December 19, 1990, I handed my division manager my resignation letter, effective January 2, 1991. To say that I was reluctant to tell him is, at best, an understatement. I was so scared that I was trembling. When he read the letter, the look on his face broke my heart. I felt as if I had blindsided him, that I was letting him down.
The worst part was that I could not give him the real reason for my decision. I told him I was leaving for 'personal reasons.' It was difficult to look him in the eye and not level with him. I am a straightforward person and felt guilty and deceitful for not being truthful, but I believed that it was necessary to remain a 'closet' bipolar. Our meeting ended amicably, and I was relieved to have that hurdle behind me.
December 19: I am proud of my accomplishments as a pharmaceutical representative. I feel excellent about my decision to leave. The pressure of this job is enormous. I feel as if a weight has been lifted from my shoulders. I am now free to concentrate on our next step.
I realize that this journal entry contradicts how I was feeling during the meeting with my manager. I referred to this entry whenever I felt twinges of remorse about leaving my career.
Fred and I knew that it was important for me to work part time. After I graduated from college, a significant part of my identity and self-worth was bound up in my career. A job also gave me a feeling of achievement. Financially, it was not necessary for me to work, but contributing to the household income had always been important to me; it gave me a feeling of autonomy. I was afraid that now I'd have trouble cutting back on my spending, and I knew that discontinuing lithium would make me more prone to shopping sprees.
Working part time was therefore a logical decision for our situation. You need to assess what is best for you and your family.
Stress is a precursor to bipolar symptoms. For example, stress causes my mind to race. When my mind is racing, it does not stop; I am thinking continuously. During conversations with others, it's extremely difficult for me to concentrate on what they're saying. My mind is often occupied with several sidebar conversations. Sometimes I try to think of ways to speed up the conversation because it's painful to converse at what I perceive as a slow pace in others. It is also difficult to act as if none of this is going on. Others are usually unaware of the turmoil that is going on in my head. Over the years, self-discipline has enabled me to appear normal when my mind is racing. While I was off the medication and I became exceedingly revved up due to stress, I could no longer conceal my racing mind. (I will explain this more throughout the book.)
Trying to sleep at night can be frustrating. Despite the fact I am tired, my mind is not; it's wound up tight. I feel as if my mind is not connected to me. It keeps thinking and thinking, and I have no control over it. Bipolar symptoms make it hard to sleep, and lack of sleep increases bipolar symptoms. It's a vicious cycle.
Fred and I believed that my working part time would meet our objectives while decreasing my stress level, so I answered an ad in the newspaper for a part-time marketing consultant for a trade show. I interviewed for the job and was hired. My primary responsibilities included contacting business owners and managers and selling the benefits of participating in an area trade show.
December 19 [continued]: I'm looking forward to starting my new job as a marketing consultant in January. Everything's falling into place. The conditions involving this decision couldn't be better. I have support from Fred, my family, and friends!
Three weeks later I wrote a journal entry that demonstrated the intense emotions and challenges I experienced as a result of giving up my career as a medical center representative. Writing down my feelings helped me to actively work through my apprehension and anxiety. Although my job had been demanding and stressful, it was also gratifying. Now I felt as if I were fading into a shadow of the competent person I once was. It really scared me.
January 6, 1991: On December 28, I drove my company car and all the company belongings to my former division manager's house [he lived about fifty-five miles from me, so I had plenty of time to grieve the loss of my career]. I've been sad and depressed about resigning since December 19. I was devastated during the ride back from Lansing that day. I felt empty and cried throughout the ride home. The reasons I'm feeling this way are as follows: (1) A large portion of my self-esteem is derived from my prior job. (2) I liked being a medical center representativeI really liked my job! (3) Calling my key contacts to tell them that I was leaving (especially at my open-heart hospitals) was extremely difficult. I wanted to share my exciting news with them but knew it wouldn't be appropriate. When asked, I believed I had to tell them I was leaving for personal reasons. The majority of them told me they'd miss me and that I was/am a very good representative: dependable, knowledgeable, and professional. I was flattered by their comments. I feel a connection to some of them; I feel as if they're my accounts. I provided them with excellent servicetook good care of them. (4) I feel as if I'm permanently closing the door to a career that's become a huge part of my identity and my life. (5) I'm going to have to adjust to not making as much money. I'm not worried about that now, but it will be something that I'll have to work on in the future.
On the positive side it sure feels great to have my 'life' back again. I'm looking forward to spending more quality time with Fred, cooking [it's funny that I mentioned cooking, because my family and friends know that I make quick and simple meals], working out, and spending time with friends. No more overnights, driving 600–900 miles per week, or extensive planning and paperwork. I started my new job January 3. I look at this job as temporary. I know it won't utilize my skills or challenge me like my previous job. However, this position is perfect for me now. It will be interesting to see if I'll be able to work once I go off lithium.
A week later I acknowledge the frustrations of my new job and give myself a pep talk.
January 14: There is a lot of potential (considering it's part time and flexible) to make money in this position. Try not to get discouragedI know that I'll be closing lots of sales soon. Keep working at it each day; I'm certain my efforts will pay off. This position is temporary for me. It's a vehicle to keep me employed during this time, to enable me to make some money, have a positive focus, and keep up my self-esteem (professionally). All of these things will help Fred and me to reach our goals.
Fred and I didn't spend much time discussing the question 'What if we have a child who is later diagnosed as bipolar?' If we had had a crystal ball that told us that both of our children would have bipolar disorder, we still would have moved forward with our decision. It wasn't a concern for us. Fred and I were confident that we could overcome that challenge if it happenedand it did. Katherine Kay was diagnosed with bipolar disorder in 2004but that's another story, literally. I have truly been embracing my bipolar condition since my college days. For me it has been a blessing in disguise.
We Decide to Have a Second Baby
Our decision to try to conceive a second baby was easier than the first decision. Fred and I kept an open mind for two years while I was back on lithium. After the birth of our first baby on December 8, 1991, and before resuming lithium, I was obsessing about having only one child. (Chapter 9 elaborates on my thought process at that volatile time. Decisions of this magnitude should not be made while you're off medication.)
Before you resume medication, concentrate on your new baby. There's no reason to think about having another at this point. Fred and I knew when the time was right. We waited until we had the same burning desire we did the first time. We had a better idea of what to expect and were confident that we could manage each phase of the pregnancy. It never occurred to us that I might not be able to conceive a second time, but if that had been the case, we would have accepted it with disappointment.
A friend and former coworker mentioned to me that her company was interested in hiring an experienced pharmaceutical representative. This occurred while we were thinking of baby number two.
November 23, 1993 [I had not written in my journal since I resumed taking lithium nine weeks after Katherine was born]: Fred and I decided to have another baby. Katherine would surely enjoy a brother or sister.
December 2: I'll let my friend know that I'm not interested in a full-time pharmaceutical position with another company. Fred and I seriously considered the pros and cons of having a second baby, and our priorities were crystal clear.
As part of the decision-making process, we agreed it would be best if I had a career with flexible hours. I decided to study to become an investment advisor representative. My father is in the financial and estate planning business. He was thrilled with my decision. I was confident that I could start the licensing and training process during my pregnancy.
This was a pivotal decision, because I needed something significant to concentrate on (above and beyond my husband and wonderful daughter) during my pregnancy. It was also important for me to work at a career that expanded my mind, offered challenges, and enabled me to help others.
Everyone has a unique set of circumstances that must be considered. It's crucial to have the support of your partner, because he or she has to help you through this potentially difficult time. Discuss some specific ways to help decrease your stress level (e.g., sharing in the household responsibilities). Extra patience is also important.
Fred says the following:
Once Kristin and I decided to have a baby, I knew that I had to help her as much as possible during this unpredictable time. Being off her medication would be a huge challenge for both of us. I felt that any way I could reduce stress in her life and reinforce positive activities, such as walking, playing cards, or enjoying a movie together, would help keep her on track.
Consider the challenges you might encounter in your relationships when experiencing possible mania and/or depression. Refer to Chapters 3 and 4 for specific suggestions to help monitor your behavior changes. It is imperative that all major decisions be made prior to discontinuing medication or once medication is resumed. This is important because significant decisions require judgment and detailed planning, both of which can be impaired while you are off medication.
It might benefit you and your partner to have a written plan that describes how you are going to make the necessary lifestyle changes to accomplish your goal of having a healthy baby.
Let's take another look at the decision to work outside the home. The financial consequences of decreasing your hours, changing jobs to work part time, or quitting your job can impact your ability to pay your bills. That's an important consideration. If you decide to try to work at your current job, and if you choose to go off medication, there is a chance that your stress level will increase dramatically, possibly causing you to get fired or quit in a manic moment. Write down a contingency plan so that you are prepared if this occurs. For example, if your income is necessary to pay the bills and you do quit your job, you might decide to stop trying to conceive, resume taking your medication, and look for another job.
Talk with your psychiatrist and health care provider about the best plan of action concerning possible medication changes. I had an ob-gyn; you might choose to use a nurse-midwife, family practitioner, nurse practitioner, or physician's assistant. Do not deviate from these professionals' recommendations; they are the experts. Ongoing communication with them is important.
If you are going to discontinue your medication prior to conception, decide on a specific length of time to try this. If you adjust well during this time, you might feel comfortable staying off your meds. However, it can take years for some women to get pregnant, if at all. As part of your written plan, be sure to follow the advice of your partner, psychiatrist, and ob-gyn to resume medication if your bipolar symptoms warrant it. You should also discuss with your physician(s) the option of resuming medication during your pregnancy if your life is at risk because of your bipolar symptoms.
Writing down a time limit to be off medication (while you are feeling stable) can help to decrease any disappointment or guilt you experience if you have trouble conceiving. During a manic or depressive episode, it's difficult to make good decisions. Your ob-gyn will be able to provide you with suggestions for how to decrease the time from conception to restarting medication.
Women who are affected with bipolar disorder (and their partners) have several things to consider while deciding if they should attempt to conceive. It is also important to do the following:
• Educate yourself and your partner on bipolar disorder (see Chapter 10).
• Consult with your psychiatrist and ob-gyn.
• Schedule an appointment with a genetic counselor for preconception planning.
• Research the risks to your baby and yourself.
• Formulate a written plan to guide you through the pregnancy process.
• Prepare for lifestyle and/or career changes to decrease stress levels.
• Implement the changes.
• Keep a journal to document your progress and thought process.
The next step is to plan for pregnancy.
©2007.Kristin K. Finn. All rights reserved. Reprinted from Bipolar and Pregnant. No part of this publication may be reproduced, stored in a retrieval system or transmitted in any form or by any means, without the written permission of the publisher. Publisher: Health Communications, Inc., 3201 SW 15th Street , Deerfield Beach , FL 33442.